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Thursday, November 27, 2008

Harry Houdini's death always seemed a little suspect to me. The story I had heard was that someone punched him the stomach so hard (because Houdini had claimed he could take any punch) that Houdini collapsed and died. According to Wikipedia, not so (well, not exactly anyway):

The eyewitnesses were students named Jacques Price and Sam Smilovitz (sometimes called Jack Price and Sam Smiley). Their accounts generally agreed. The following is according to Price's description of events. Houdini was reclining on his couch after his performance, having an art student sketch him. When Whitehead came in and asked if it was true that Houdini could take any blow to the stomach, Houdini replied in the affirmative. In this instance, he was hit three times, before Houdini protested. Whitehead reportedly continued hitting Houdini several times afterwards, and Houdini acted as though he were in some pain. Price recounted that Houdini stated that if he had had time to prepare himself properly, he would have been in a better position to take the blows.[26] Although in serious pain, Houdini nonetheless continued to travel without seeking medical attention. Harry had apparently been suffering from appendicitis for several days and refusing medical treatment. His appendix would likely have burst on its own without the trauma.[27]

When Houdini arrived at the Garrick Theater in Detroit, Michigan, on October 24, 1926, for what would be his last performance, he had a fever of 40°C degrees (104 F). Despite a diagnosis of acute appendicitis, Houdini took the stage. He was reported to have passed out during the show, but was revived and continued. Afterwards, he was hospitalized at Detroit's Grace Hospital.[28] Houdini died of peritonitis from a ruptured appendix at 1:26 p.m. in Room 401 on October 31 (Halloween), 1926, at the age of 52.

After taking statements from Price and Smilovitz, Houdini's insurance company concluded that the death was due to the dressing-room incident and paid double indemnity.

Monday, November 24, 2008

As previously discussed on this blog, medical deportations are a tragic reality. The cases are sad enough when the deportees are illegal immigrants, but what happens if they are in fact legally in the U.S.? Another shameful medical deportation:

Soon after Antonio Torres, a husky 19-year-old farmworker, suffered catastrophic injuries in a car accident last June, a Phoenix hospital began making plans for his repatriation to Mexico.

Mr. Torres was comatose and connected to a ventilator. He was also a legal immigrant whose family lives and works in the purple alfalfa fields of this southwestern town. But he was uninsured. So the hospital disregarded the strenuous objections of his grief-stricken parents and sent Mr. Torres on a four-hour journey over the California border into Mexicali.

For days, Mr. Torres languished in a busy emergency room there, but his parents, Jesús and Gloria Torres, were not about to give up on him. Although many uninsured immigrants have been repatriated by American hospitals, few have seen their journey take the U-turn that the Torreses engineered for their son. They found a hospital in California willing to treat him, loaded him into a donated ambulance and drove him back into the United States as a potentially deadly infection raged through his system.

By summer’s end, despite the grimmest of prognoses from the hospital in Phoenix, Mr. Torres had not only survived but thrived. Newly discharged from rehabilitation in California, he was haltingly walking, talking and, hoisting his cane to his shoulder like a rifle, performing a silent, comic, effortful imitation of a marching soldier.

“In Arizona, apparently, they see us as beasts of burden that can be dumped back over the border when we have outlived our usefulness,” the elder Mr. Torres, who is 47, said in Spanish. “But we outwitted them. We were not going to let our son die. And look at him now!”

Antonio Torres’s experience sharply illustrates the haphazard way in which the American health care system handles cases involving uninsured immigrants who are gravely injured or seriously ill. Whether these patients receive sustained care in this country or are privately deported by a hospital depends on what emergency room they initially visit.

There is only limited federal financing for these fragile patients, and no governmental oversight of what happens to them. Instead, it is left to individual hospitals, many of whom see themselves as stranded at the crossroads of a failed immigration policy and a failed health care system, to cut through a thicket of financial, legal and ethical concerns.

While one can empathize to some degree with hospitals that do not have the funds to adequately care for patients with questionable legal status, knee-jerk deportations are certainly not the solution. While deportations may be necessary in some cases, they should clearly be a last resort and even then, only instituted by the proper legal authorities, not in an unregulated manner by hospitals. The problem is systemic, but it is one we should all be ashamed of.. Patients, legal or not, deserve better.

Wednesday, November 19, 2008

Kidney disease is on the rise in the United States, yet it still gets less attention than other diseases such as cancer. Many factors, such as high blood pressure or even carbonated beverages, contribute to the disease. Regardless of the cause though, the burden of dialysis treatment takes a toll not only patients but on the healthcare system as a whole. For many, awareness of chronic kidney disease comes too late:

In February 2005, Rita Miller, a party organizer in Chesapeake, Va., felt exhausted from what she thought was the flu. She was stunned to learn that persistent high blood pressure had caused such severe kidney damage that her body could no longer filter waste products from her blood.

“The doctor walked over to my bed and said, ‘You have kidney failure — your kidneys are like dried-up peas,’ ” recalled Ms. Miller, now 65, who had not been to a doctor or had her blood pressure checked for years.

“The doctor said, ‘Get your family here right away,’ ” she said. “They were telling me I might not make it. I was in shock. I started dialysis the next day.”

Ms. Miller, who has since moved to Connecticut to be with her children, was one of the millions of Americans unaware that they are suffering from chronic kidney disease, which is caused in most cases by uncontrolled hypertension (as in her case) or diabetes, and is often asymptomatic until its later stages. The number of people with the disease — often abbreviated C.K.D. — has been rising at a significant pace, thanks in large part to increased obesity and the aging of the population.

An analysis of federal health data published last November in The Journal of the American Medical Association found that 13 percent of American adults — about 26 million people — have chronic kidney disease, up from 10 percent, or about 20 million people, a decade earlier.

It is clear why CKD has a great impact on patients' lives, but why does chronic kidney disease have such a large impact on the system?

In 2005, more than 485,000 people were living on dialysis or with a transplant, at a total cost of $32 billion. Medicare pays for much of that, because it provides coverage for patients needing dialysis or transplant even if they are not yet 65. In fact, kidney disease and kidney failure account for more than a quarter of Medicare’s annual expenditures.

In other words, unlike almost any other disease, the federal government fully covers treatment for nearly everyone requiring dialysis, due to a quirk in the law. Therefore, moreso than any other condition, CKD becomes a disease that society as a whole must grapple with, especially as its incidence rises.

Tuesday, November 18, 2008

Jules the Robot is the first humanoid robot (see video at bottom of the page after the jump). This isn't particularly related to medicine, but I just found the video so eerie I thought I should post it:

Scientists have created the first 'humanoid' robot that can mimic the facial expressions and lip movements of a human being.

'Jules' - a disembodied androgynous robotic head - can automatically copy the movements, which are picked up by a video camera and mapped on to the tiny electronic motors in his skin.

It can grin and grimace, furrow its brow and 'speak' as his software translates real expressions observed through video camera 'eyes'.

As I said, this isn't directly medically related, but one can envision this technology being used to make more realistic robots for students and residents to train on, with the "patient" robot grimacing if students examine it too roughly, or laughing if they're being tickled. Advances like this also make me wonder whether medical ethics can keep up with the pace of innovation.

Monday, November 17, 2008

Google Flu Trends is a new system set up by Google through its Google.org philanthropy site that tracks American's search queries related to the flu. Apparently, Americans turn to Google before turning to their PCP when trying to decide what their symptoms mean. Now, Google has started to look at this data in the aggregate with Google Flu Trends:

There is a new common symptom of the flu, in addition to the usual aches, coughs, fevers and sore throats. Turns out a lot of ailing Americans enter phrases like “flu symptoms” into Google and other search engines before they call their doctors.

That simple act, multiplied across millions of keyboards in homes around the country, has given rise to a new early warning system for fast-spreading flu outbreaks, called Google Flu Trends.

Tests of the new Web tool from Google.org, the company’s philanthropic unit, suggest that it may be able to detect regional outbreaks of the flu a week to 10 days before they are reported by the Centers for Disease Control and Prevention.

In early February, for example, the C.D.C. reported that the flu cases had recently spiked in the mid-Atlantic states. But Google says its search data show a spike in queries about flu symptoms two weeks before that report was released. Its new service at google.org/flutrends analyzes those searches as they come in, creating graphs and maps of the country that, ideally, will show where the flu is spreading.

The C.D.C. reports are slower because they rely on data collected and compiled from thousands of health care providers, labs and other sources. Some public health experts say the Google data could help accelerate the response of doctors, hospitals and public health officials to a nasty flu season, reducing the spread of the disease and, potentially, saving lives.

Seems like a smart idea. I wonder if Google will apply this to other diseases as well. Going beyond infectious diseases, what if Google were to track search queries related to other potential 'trends' like teen pregnancy? Should raise some interesting questions about how to utilize this technology for public health issues while respecting the privacy of Google users.

Friday, November 14, 2008

Lindsay Lohan in the movie "Mean Girls" demonstrates the stereotypical view of popularity in a high school setting with a few semi-realistic twists. However, an interesting piece in the NYTimes a while back about looked at the real lives of teenagers and how one's place on the popularity scale during adolescence affects their social standing in the future, and perhaps their health. Where were you on the popularity scale?

The cult of popularity that reigns in high school can look quaint from a safe distance, like your 20th reunion. By then the social order may have turned over like an hourglass: teenagers who were socially invisible have emerged as colorful characters, confident, transformed. Others seem preserved in time, same as ever, while some former princes and queen bees are diminished or simply absent, now invisible themselves.

For years researchers focused much attention on those prominent teenagers, tracking their traits and behaviors. The studies found, to no one’s surprise, that social dominance in adolescence often involves an aggressive, selfish streak that may not play well outside the locker-lined corridors.

The cult disbands, and the rules change.

Yet high school students know in their gut that popularity is far more than a superficial, temporary competition, and in recent years psychologists have confirmed that intuition. The newer findings suggest that adolescents’ niche in school — their popularity, and how they understand and exploit it — offers important clues to their later psychological well-being.

Not too surprisingly, the kids who were the most 'social' in high school seem to do better in the long run, since a social person will (should?) always be well-liked in society, but one can only be a prom/homecoming queen once. Besides, having social skills is marketable asset. From a medicine standpoint, I wonder if more attention should be paid to such social trends by adolescent psychiatrists. Furthermore, if one can identify kids at risk, those at the lowest rungs, how does one approach them? Try to teach them social skills? Put them in an environment where they are better able to socialize? I think there will always be an "in" group and an "out" group among adolescents but the key here needs to be to identify the teens who are at risk for having a poor self-image and low self-worth, regardless of how 'popular' they seem to be, and then find a way to help them grow and achieve a lasting sense of self-worth.

Wednesday, November 12, 2008

A new case report out of Germany seems to have found a potential cure for AIDS. Yes, I said 'cure.' The doctor, a hematologist-oncologist, was treating an HIV positive patient for leukemia. Here's how he came upon the potential cure for AIDS:

The breakthrough appears to be that Dr. Hütter, a soft-spoken hematologist who isn't an AIDS specialist, deliberately replaced the patient's bone marrow cells with those from a donor who has a naturally occurring genetic mutation that renders his cells immune to almost all strains of HIV, the virus that causes AIDS.

The development suggests a potential new therapeutic avenue and comes as the search for a cure has adopted new urgency. Many fear that current AIDS drugs aren't sustainable. Known as antiretrovirals, the medications prevent the virus from replicating but must be taken every day for life and are expensive for poor countries where the disease runs rampant. Last year, AIDS killed two million people; 2.7 million more contracted the virus, so treatment costs will keep ballooning.

While cautioning that the Berlin case could be a fluke, David Baltimore, who won a Nobel prize for his research on tumor viruses, deemed it "a very good sign" and a virtual "proof of principle" for gene-therapy approaches. Dr. Baltimore and his colleague, University of California at Los Angeles researcher Irvin Chen, have developed a gene therapy strategy against HIV that works in a similar way to the Berlin case. Drs. Baltimore and Chen have formed a private company to develop the therapy.

Back in 1996, when "cocktails" of antiretroviral drugs were proved effective, some researchers proposed that all cells harboring HIV might eventually die off, leading to eradication of HIV from the body -- in short, a cure. Those hopes foundered on the discovery that HIV, which integrates itself into a patient's own DNA, hides in so-called "sanctuary cells," where it lies dormant yet remains capable of reigniting an infection.

But that same year, researchers discovered that some gay men astonishingly remained uninfected despite engaging in very risky sex with as many as hundreds of partners. These men had inherited a mutation from both their parents that made them virtually immune to HIV.

The mutation prevents a molecule called CCR5 from appearing on the surface of cells. CCR5 acts as a kind of door for the virus. Since most HIV strains must bind to CCR5 to enter cells, the mutation bars the virus from entering. A new AIDS drug, Selzentry, made by Pfizer Inc., doesn't attack HIV itself but works by blocking CCR5.

About 1% of Europeans, and even more in northern Europe, inherit the CCR5 mutation from both parents. People of African, Asian and South American descent almost never carry it.

Dr. Hütter, 39, remembered this research when his American leukemia patient failed first-line chemotherapy in 2006. He was treating the patient at Berlin's Charité Medical University, the same institution where German physician Robert Koch performed some of his groundbreaking research on infectious diseases in the 19th century. Dr. Hütter scoured research on CCR5 and consulted with his superiors.

Finally, he recommended standard second-line treatment: a bone marrow transplant -- but from a donor who had inherited the CCR5 mutation from both parents. Bone marrow is where immune-system cells are generated, so transplanting mutant bone-marrow cells would render the patient immune to HIV into perpetuity, at least in theory.

Sounds interesting, but given the mortality rate of bone marrow transplants, it probably won't be a widespread treatment for a while.

Monday, November 10, 2008

Health insurance mandates are a major topic these days. Basically, to get around the politically difficult challenge of implementing truly universal healthcare, politicians and legislatures have embraced mandates as a stop-gap measure. Instead of providing care, these entities mandate individuals to obtain care for either themselves or their family members (i.e., their children) or face penalties. While in theory this should increase the rates of coverage to near-universal, it is not actually a guarantee of providing adequate care to anyone or to everyone.

My support of mandates has waxed and waned over time. It seems like they could be a good idea, but it really depends on how their implemented and enforced. If done poorly, they could actually do more harm than good. Healthcare Economist has a few thoughts on the same topic in Thoughts on individual mandates:

Health insurance require that all individuals buy health insurance. Most voters views on an individual mandate depend on how you frame the question. If you ask voters: “Should everyone buy health insurance?” Most people will say yes.

If you ask “Should the government compel all ndividuals to buy health insurance regardless of the cost?” Then the response is much less positive.

Keep reading to see what else he has to say. Interesting stuff, and an issue that potentially may affect all of us in the near future.

Thursday, November 06, 2008

There's an interesting Supreme Court case coming up. The case deals with whether drug-makers are liable for side-effects of medications that occur, even after the drug label/warning is approved by the FDA. There's an interesting discussion about patients vs. big pharma on the Healthbeat Blog (via KevinMD):

First, the details of the case: In the spring of 2000, Diana Levine of Vermont received treatment for migraines which consisted of the painkiller Demerol and Phenergan, an antihistamine manufactured by Wyeth Pharmaceuticals. Phenergan is typically injected directly into the muscle or dripped into the vein through steady doses (a procedure called an “IV drip”). When administering the drug, clinicians must be careful not to expose it to blood in the arteries; doing so causes “swift and irreversible gangrene,” to use an evocative phrase from a September New York Timesarticle on Levine’s case.

Unfortunately, the physician assistant who attended to Levine administered Phenergan neither through muscular injection nor IV drip, but through a process called “IV push”—a direct intravenous shot in the arm. The assistant missed and hit an artery. Over the next few weeks, Levine, who was an avid guitarist, saw her right hand and forearm turn purple and then black—until both were finally amputated.

The court battle is over whether or not Wyeth Pharmaceuticals sufficiently warned against the dangers of IV push on its packaging for Phenergan—packaging that had been approved by the FDA. The drug’s labeling did warn that it was preferable to give Phenergan through IV drip, and warned that “inadvertent intra-arterial injection”—accidentally injecting the drug into an artery—could cause “gangrene requiring amputation.” But nowhere on the Phenergan label was there an express warning that the method of IV push is extremely risky for this very reason.

Wednesday, November 05, 2008

An interesting attempt by the CEO of Beth Israel Deaconess Hospital in Boston to be more open about the errors that occur in his facility (via KevinMD). Openness about hospital errors has its price though:

For the past year, Paul Levy, president of Beth Israel Deaconess Medical Center, has more than ever before staked his reputation on "transparency," particularly about medical errors inside his Harvard teaching hospital.

In January, he made a splash when he announced the hospital would aim to eliminate all preventable harm to patients within four years and would publish quarterly reports on its progress. Whether speaking from a podium or writing on his blog, Levy maintains that admitting and learning from serious mistakes is far more important than avoiding public-relations blows.

This stance has won him praise in some quarters - and, in recent months, has sorely tested him as well.

In late June, news broke that a cosmetic surgeon was fired after he appeared to be dozing while performing a liposuction procedure. A few days later, a veteran surgeon completed surgery on a woman's ankle - only to discover it was the wrong ankle.

Earlier this month, an anesthesiologist, who had battled drug addiction and been terminated a year earlier, was found dead in a hospital closet, a possible suicide. And just last week, a 37-year-old Medford woman died during an emergency caesarean section at the hospital; her baby has survived.

Other controversies have erupted under Levy's leadership this year as well, including a management shake-up in the surgery department, complaints of overworked surgery residents, and bitter volleys between Levy and a national union trying to organize the hospital's workers. The union chronicles a range of complaints on a website called "Eye on BI" and on bus shelter advertisements, and accuses Levy of promoting "corporate-style medicine."

Yet sitting in his office last week, the 58-year-old chief executive officer displayed an upbeat attitude, saying he refuses to let the publicity about these issues rattle his mission to make his 621-bed hospital, which performs about 9,000 surgeries a year, one of the most aggressive in confronting problems.

While the efforts deserve to be applauded, I think there is a risk that such errors will be sensationalized to the detriment of the hospital. As the article notes, without putting the error rate in context (ie, with a comparison to the error rates at other hospitals), the CEO is putting the hospital at risk of garnering a negative public impression, even though the hospital is likely outperforming its peers. Still, I guess someone has to lead the way, so kudos to BID.

Tuesday, November 04, 2008

Surgeon and author Pauline Chen recently wrote about medical student burnout in the NYTimes:

Medical school was not easy for me. I knew that I wanted to become a doctor to help people, but I had given little thought to the process. I was poorly prepared for many things: the pressure to excel in ways that seemed so far from caring for people; rapidly mounting debts I signed off on every semester; a roller coaster existence from chronic lack of sleep; hazing from the more experienced students and residents; and the realities of patient suffering despite my best efforts.

Even surgical residency, despite the relentlessly long hours, seemed so much closer to what I wanted to do.

Some of my professors tried to “humanize” the process. They invited us to dinner in their homes, supported our extracurricular efforts to set up health screening clinics in low-income neighborhoods, and tried to make our basic science courses more relevant to working with patients. But sitting where I am now, as someone who teaches medical students and who loves helping others as a doctor, I can understand the challenge they faced. Given the fire hose of information medical students must learn in just four years, how does one ever gently take a sip?

Despite my teachers’ efforts, I was about as miserable in medical school as I had ever been. I felt alone. Neither I nor my classmates could admit to failure, and the last thing I wanted to do was to let anyone but my closest friends know just how unhappy I was. Success in medical school was the first step to a future of helping others, and I was not about to jeopardize that.

What implications does this have for these students' performance as physicians?

In a third study, Dr. Dyrbye found that when tested for empathy, medical students at baseline generally scored higher than their nonmedical peers. But, as medical students experienced more burnout, there was a corresponding drop in the level of empathy toward patients.

Not too surprising when you think about it, but to have concrete data underscores the point. The especially distressing part was that about 10% of respondents to their surveys had considered suicide at some point during medical school. The article notes that the LCME has advocated having "Wellness" be a focus of medical education, but from my experience, simply providing the resources is not enough. Medical schools need to emphasize more socialization and honest communication between students, residents, and faculty. Without this, simply naming someone a counselor or providing a resource will not reverse this trend.

Monday, November 03, 2008

Has this happened to any of you? You're rounding with your attending. Perhaps bored, perhaps hungry, half paying-attention. You listen in a little more closely when it's your patient, but find it harder to keep track of what is going on when the patient is someone else's. The attending comes across a patient with a new diagnosis. The resident or fellow medical student talks a little bit about the case. The attending digests the information, and then turns and spits it out at the patient before hurriedly moving on to the next patient. You turn to leave, but before doing so, thank the patient, who weakly smiles and nods back, and you suddenly realize: he doesn't even speak English!

Okay, perhaps that's a bit extreme as an example, but it is striking to me sometimes how poor the communication between doctor and patient is. The story above is one extreme; the other extreme, which is perhaps the ideal, is a physician who patiently sits at the bedside, explains the situation in terms the patient can understand, and then calmly answers all their questions.

In my view, there are two problems with this 'ideal' communicator. First, given the nature of how hospitals work and how the healthcare system is in general, there is little incentive to provide patients with this full explanation (save one's own principles). Primary care physicians have a limited amount of time to see each patient and cannot feasibly explain and answer all of their questions.

Furthermore, this view does not take into account patient psychology. Many patients, especially since they are ill, tend to enter a submissive mode. They listen as best they can, but their minds are probably more focused on the days they're missing from work, or who's going to take care of the kids, or how they will pay all these bills. They are not in the right frame of mind to absorb all this new information, proccess it, and then ask intelligent questions. Or, they simply do not have the requisite medical knowledge to even start to understand.

What to do? I am sure there is no perfect solution here, but I think this ideal of having a physican behave as a neutral source of information who answers questions is incomplete. I think a more practical solution is a doctor who gives a brief 2 minute explanation of a new diagnosis and the key points that the patient has to be aware of now. Then, instead of making themselves available to answer questions, the physician should ask the patient to explain their illness back to the physician, and then answer the physician's questions. Of course, after this, the physician should fill in any gaps and offer to answer questions as well. Sometimes though, I think it would be better simply to explain the situation in the first visit as I just described, and then offer to answer questions the next time you see the patient after they have had some time to digest the diagnosis.

Imagine a patient who came in with DKA and now has a new diagnosis of Type I Diabetes. Simply telling them this and sending them on their way is not sufficient. Hopefully the facility has a good diabetes educator, but if they don't, it behooves the doctor to make sure that the patient understands the diagnosis, and perhaps more importantly, how to care for themselves. Whether or not the patient understands pancreatic function is less important than whether the patient knows how to dose and administer their insulin, or what symptoms should prompt them to seek medical attention. I feel like for common diagnoses, physicians should have some standardized guide as to what education should be provided to the patient prior to discharge.

Perhaps some patient may find such behavior too paternalistic. But, as physicians, we should avoid making assumptions about our patients as much as possible. To me, this means that instead of treating each patient as the average patient with the average level of understanding, we must treat each patient as the one with the lowest level of understanding. While this does reinforce the stereotype of the paternalistic physician, I believe I'd rather err on the side of paternalism in order communicate more effectively, rather than act as some sort of neutral physician ideal, and let my patient smile and nod their way to poorer health.